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Dimensions of Dental Hygiene is committed to the highest standards of professionalism, accuracy and integrity in our mission of education supporting oral health care professionals and those allied with the dental industry. Through our print and digital media platforms, continuing education activities, and events, we strive to deliver relevant, cutting-edge information designed to support the highest level of oral health care.

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The most profound change ever to affect
oral prophylaxis occurred in 1976 with the
advent of selective polishing, which was
introduced in the fourth edition of Clinical Practice of the Dental
Hygienist by Esther M. Wilkins, BS, RDH, DMD.1 The text
stated: "Polishing is a selective procedure and not every
patient needs to have the teeth polished, especially on a routine
basis."1 In practice, selective polishing meant that only
stained teeth received prophylaxis, and polishing to remove
plaque was not necessary because patients could perform this
function themselves.

Selective polishing was a response to the concern that abrasives
in polishing pastes removed the fluoride-rich outer layer of
enamel. This theory was based on a study that found 4 µm of
enamel was removed during a 30-second polishing with a
pumice-water slurry.2 Selective polishing was also supported by
the fact that polishing for stain removal is not classified as a therapeutic
procedure. Proponents of selective polishing suggested
that instead of polishing, dental hygienists should spend their
time preventing or arresting caries and/or periodontal diseases,
providing individualized treatment plans, and educating patients
about oral health self-care techniques.1

Selective polishing may have found support among clinicians,
but patients were another matter. Most still desired the
oral prophylaxis that left them with the smooth, clean, polished
feeling that was "proof" they had received a complete
dental cleaning.3 Some patients felt like they were being
cheated, while others accused dental hygienists of being lazy.4 This dilemma was made even more confusing by the fact that
both the American Dental Hygienists' Association and the
American Academy of Periodontology included polishing in
their definition of oral prophylaxis.3

The Tide Turns

Dental hygiene is dynamic, with change occurring frequently
across all facets of care. Today, evidence-based decision making
is the framework for all patient care decisions. No scientific
proof shows how much enamel is removed during
polishing procedures—if it is removed at all.4 The original
study that reported the removal of enamel after polishing was fraught
with problems. Notably, the sample size was too small, there
were too many uncontrolled and/or undisclosed variables that
affected the outcome, and the polishing procedure used did not
mirror realistic clinical polishing techniques.2

Enamel remains an enigma and we have much to learn, especially
about its thickness and smoothness. Enamel is in a constant state of
demineralizing and remineralizing.5 Therefore, if microns of enamel are
removed by polishing, it may remineralize in time with salivary minerals
and exposure to fluoride, especially if the patient receives a fluoride
treatment after the polishing procedure.

Cleaning agents are also a viable alternative to traditional prophylaxis
polishing agents. Cleaning agents contain no abrasives and do not compromise
the surface integrity of teeth or esthetic restorations, while still
producing a high luster.4 Cleaning agents can be used any time polishing
is indicated, but are especially helpful when polishing teeth with little
or no stain, the appropriate polishing agent for an esthetic material is
unavailable, or the type of restorative material is unknown.

Polishing—whether with a cleaning agent, polishing agent, or specially
formulated paste designed for esthetic restorations—produces
smooth surfaces on teeth and restorations that reduce the adherence of
oral accretions, such as dental biofilm and extrinsic stains. Polishing is
used during many dental procedures, including stain and plaque
removal.6 As procedures to whiten and brighten smiles have become
some of the most popular in dentistry, it is clear that consumers desire
an attractive smile. Patients expect to have their teeth polished and
leave the dental appointment with that "smooth" feeling. Even during
the era of selective polishing, dental hygienists continued to provide
patients with oral prophylaxis, which is confirmed by the amount of polishing
products sold each year.4

Essential Selective Polishing

Dental hygienists can now feel free to polish all teeth—stained or
unstained—as selective polishing has been redefined as essential selective
polishing.7 Essential selective polishing is based on scientific and clinical
evidence—dental hygienists should select cleaning or polishing agents
according to the individual patient's needs. This new definition will appear
in the 11th edition of Wilkins' Clinical Practice of the Dental Hygienist,
which will be published this year.7

The
place to initiate essential selective polishing is during the oral
examination. Does the patient have any stained teeth or esthetic
restorations? Are the esthetic restorations stained? Some conditions
do
contraindicate polishing, such as amelogenesis imperfecta, enamel
demineralization, enamel hypocalcification, enamel hypoplasia,
exposed cementum, and dentinal hypersensitivity. Once the patient's
polishing needs are determined, the dental hygienist must select the
correct cleaning or polishing agent to meet those needs.

If the patient has stained teeth and no esthetic restorations, the prophylaxis
polishing agent selected (fine, medium, or coarse) should be the
least abrasive necessary to remove the stains. If a patient has stains and
esthetic restorations, the appropriate paste should be used only on the
teeth, not on the restorations. While cleaning agents can be used on all
restorative materials, a polishing paste recommended by the material's
manufacturer or designed specifically for the restorative material can be
used. Air polishing with sodium bicarbonate is safe for tooth stain
removal, provided patients meet all selection criteria. Air polishing with
any type of air polishing powder is contraindicated for esthetic restorations,
including glass ionomers, porcelain, and composites.

The essential selective polishing approach solves the "one polishing
paste for all polishing procedures" dilemma.7 Dental hygienists who
have adopted this method will use either whatever grit is available or
coarse polishing paste on everything.4,7 Both are unethical because they
ignore the patient's needs and could severely damage esthetic restorations.2 The premise for the "coarse polishing paste on everything"
approach is that the use of the coarsest polishing paste available will
remove the heaviest amounts of stain as well as the lightest amounts,
therefore saving time. Providers who polish in this ill-advised fashion
ignore the science of abrasion, which is to use the polishing grits in a
progression of coarse, medium, and fine applications, changing the rubber
cup with each grit size.4 Unfortunately, the "coarse paste on everything"
approach is widespread as demonstrated by the fact that 80% of
all prophylaxis pastes sold in the United States is coarse grit, followed by
10% in medium grit, and 10% in fine grit.8 Coarse grit polishing pastes
can cause dentinal hypersensitivity, produce rough surfaces, and accelerate
staining and the adherence of dental plaque. The surface characterization
of esthetic restorations can be highly damaged by coarse
polishing paste, even after one polishing exposure.9

Summary

The era of selective polishing is over. Polishing is an integral procedure provided
by dental hygienists. Patients look forward to the resultant smooth,
clean feeling, and dental hygienists must ensure that all patients are polished
according to their individual needs—ensuring the safety of their
teeth and restorations.

Caren M. Barnes, RDH, MS,
is a professor in the Department of Dental Hygiene and the coordinator
of clinical research at the Cruzan Center for Dental Research, at the
University of Nebraska Medical Center, College of Dentistry in Lincoln.
She is also a Dimensions Editorial Advisory Board member.